1. TRAINING RESIDENTS AND
NURSES AS PATIENT-
CENTERED CARE TEAMS
International Conference on Communication
in Healthcare
Robert C. Smith
Francesca C. Dwamena
Heather Laird-Fick
(Picker Institute Support)

2. SAFETY
ACGME and JCAH: better team-work to
enhance safety
– 70% fatal & serious errors from poor
communication among team members
Medical ward rounds important? Nurses
rarely attend

3. CARE TEAMS
What’s involved: use PCC skills with each
other  effective communication
Team formation successful in acute areas
(ICU, trauma)
No one has tried on medical wards to
increase teamwork of nurses and doctors
We developed a program to do this

4. Step 1: CONSOLIDATING
PATIENTS ON ONE WARD
Previously: patients on 10-12 different
wards -- 600 bed community hospital
Many discussions with Medical Director 
one 32-bed ward where ~2/3 of patients
now come = crucial first-step

5. Step 2: TRAINING INDIVIDUAL
NURSES & RESIDENTS
OBJECTIVES
Skills:
• Evidence-based PCC method (5 steps, 21
substeps)
• Clinical skills for common psychosocial ward
problems; e.g., depression, opiate use
Attitudes:
• Self-direction and collaborative agenda-setting
• Personal awareness, including emotional issues
that interfere with teamwork

6. TRAINING NURSES IN PCC
Authors train 3 nurse leaders: two 3-hr PCC
seminars  4 hrs bedside teaching  4 hrs on
how to teach PCC
Nurse leaders train 35 staff nurses: 4-hr seminars
(groups of 4-8)  one-on-one bedside training in
PCC (4 hrs for each staff nurse)
Maintenance:
• nurse dyads self-critique weekly
• nurse leaders critique monthly

7. TRAINING RESIDENTS IN PCC
Existing one-month full-time psychosocial rotation
• http://im.msu.edu/curricula/blockroatations/2008%20Psychosocial%20cur
• SMITH RC, MARSHALL AA, OSBORN GG, SHEBROE V, LYLES JS, STOFFLMAYR
BE, VAN EGEREN LF, METTLER J, MADUSCHKE K, STANLEY J., GARDINER JC:
Behaviorally-defined, research-based guidelines for teaching
patient-centered interviewing. Patient Education and Counseling
2000; 39:27-36.
Mental Health Management Skills
Quarterly videotaped review of PCC skills – implementation
stage

8. NURSES & RESIDENTS
• Provided textbook and DVD describing
basic PCC method
• Worked with national consultant (Richard
Frankel) during 2 visits and follow-up
video conferences
• One nurse leader and one staff nurse
attended AACH June 2009 meeting

9. TEACHING METHODS
Didactic -- <10% of time (e.g., 5 step PCC
model; treating depression; opiate misuse)
Experiential
• Role playing
• Critiques: taped & observed interactions --
real patients
• Address personal awareness at each
critique and role play  many issues

10. Step 3: TEAM-BUILDING
Trust and Respect
Faculty, Nursing Leadership, and Medical
Director = Model for later work
Develop objectives: improved patient satisfaction,
teaching, care, and nurse-doctor communication – as
trust and respect develop
Negotiate details of consolidated ward
Faculty and ward nursing leaders
– Issues: non-acute ward; many residents
– Negotiation of details as trust and respect develop
– Negotiated following approach

11. INFORMAL NURSE & RESIDENT
INTERACTIONS
1. Grand opening of ward
2. Name tags; prominent pictures with names
3. Use same conference room
4. Common eraser-board: messages, call, etc.
5. Introduce self; use first names; “thank you”
6. Watch body language
7. Make explicit who does what and when
8. Joint softball team for the ward

12. FORMAL NURSE AND RESIDENT
INTERACTIONS
1. Nurses attend morning report for their pts
2. Senior resident, charge nurse, & CM – daily (review
problems)
3. Joint chart review before rounds (problems, plans)
4. Nurses join ward rounds when their patients involved,
including bedside
5. Resident conducts chart rounds with evening shift
nurses
6. Resident attends LOS conference 2/week
7. Nurses join conferences for their patients (family, near-
miss, etc.) and express ideas & concerns
8. Awards: outstanding nurse and resident

13. BIOPSYCHOSOCIAL
CONFERENCE
• Bi-weekly residents’ a.m. report – authors,
faculty attending, nurse leaders, and nurse
involved with patient attend
• Objective:
– skills to handle difficult psychosocial issues
(depression, opiates)
– associated personal awareness issues
– support for those involved with patients
• Senior resident plans, prepares referenced
handout, and leads discussion
• Patient interviewed in conference room

14. ATTENDING FACULTY
All from GIM Division
Incorporate their initial input and ongoing
feedback with regular review quarterly
Key role: model interactions; monitor
residents; teach residents

15. RESEARCH DESIGN
RCT with post-test only evaluation
80 randomly allocated ‘no-doc’ admissions to our ward
(T) and 80 to other services (C)
Powered to achieve effect size 0.4 on primary endpoint
(patient satisfaction)
Also conducting:
1) Formative evaluation
2) Summative evaluation of impact on nurses and
residents (pre/post): interactional & teamwork
measures, satisfaction, self-efficacy
Data evaluation just beginning

16. PRELIMINARY FINDINGS
• PCC principles key to requisite
administrative interactions – joint
ownership, respect, and trust
• Nurses learn quickly, contribute
significantly, and are interested in
teamwork
• Resident equally enthused in working with
nurses – and having all patients in one
place

17. DISCUSSION
Unique teaching: training nurses and
residents to work as a team on a medical
ward, after training them in requisite PCC
skills
Data in acute units support but none in this
area – rigorous evaluation pending
Very positive feedback from administration,
nursing, residents, and faculty

18. DISCUSSION : A Caveat
Not as easy as training in PCC individually and
giving guidelines for working together
Fundamental issue: long in-grained nurse-doctor
relationship patterns = zero sum game where
nurse always loses
Ongoing relational process: developing genuine
trust & respect, overcoming institutionalized
biases, & overcoming personal biases
Progresses slowly, but it does progress if you stick
with it -- Much daily behind-the-scenes work

19. CONCLUSION
Much research supports training individuals
in PCC
= “necessary but not sufficient”
To maximize care, satisfaction, and safety,
we must expand teaching efforts to
address teamwork